Coroner's blast for social workers after Radford boy dies in his own bedroom

A CORONER has called for social workers to have more training after a schoolboy died tragically in his own bedroom.

Dylan-Oliver Lunney was described by his mother as an "incredibly intelligent" and "fiercely loyal" boy who loved life.

The 12 year old died after an incident involving a dressing gown cord at their home in Player Street, Radford.

Nottingham Coroner's Court was told he may have fallen from the top of his bunk bed and caught his neck on the cord.

But the inquest also heard that his death came after three years of domestic violence issues within his family.

Coroner for Notts Mairin Casey said social workers at Nottingham City Council "missed multiple opportunities" to help the family.

On one occasion, a plea by his mother, Rouee Lunney, for counselling for her and Dylan-Oliver was not followed up. Miss Casey said: "I've found that opportunities were missed to answer the physical, emotional and psychological wellbeing of Dylan-Oliver.

"I strongly recommend that all those who had involvement in the investigation of referrals with Dylan-Oliver be prioritised for future training."

The family came to the attention of social services in January 2009 following an incident of domestic violence involving Ms Lunney.

After a number of other referrals to social services that year, social workers visited the family after Dylan-Oliver was assaulted by a neighbour in January 2010.

Staff also received a further referral from the family's former GP in April 2010, in which the doctor reported Dylan-Oliver had been displaying "worrying behaviour".

During the inquest, Miss Casey had an exchange with social worker Rohan Griffiths, who had been assigned the family's case following the assault on Dylan-Oliver. Mr Griffiths closed the case ten days after the incident and failed to speak alone with Dylan-Oliver about his experience.

The inquest heard that council staff made the decision to close the case after feeling that Ms Lunney had been taking appropriate action in caring for her children by flagging up the incidents.

Miss Casey said: "I'm inclined to say that your personal systems in this case, for this child, were grossly inadequate."

The coroner recorded an open conclusion after four days of evidence ended yesterday.

She said: "Was this an accident? Was this a cry for help? Was this experimentation that went tragically wrong? Was it simply boy play?

"Sadly, we will never know."

Pathologist Dr Charles Padfield carried out examinations on Dylan-Oliver following his death, on April 12, 2012.

He said tests found the youngster had fainted as a result of the pressure on his neck caused by the dressing gown.

He said: "I think it was play. Boys play, and always play dangerously."

When asked by Miss Casey about the theory that Dylan-Oliver had fallen off his bed and caught his neck on the dressing gown cord, Dr Padfield said: "I have seen children who have been hanged in the most bizarre ways."

Ms Lunney said: "Dylan-Oliver loved his life. I have never met someone who has enjoyed life as much."

City Council: 'We accept there were missed opportunities'

FOLLOWING the inquest into the death of Dylan-Oliver Lunney, Alison Michalska, Nottingham City Council's corporate director for children and families, said: "The death of a young child is a tragedy and I offer my deep sympathy to the family and friends of Dylan.

"We accept that there were missed opportunities to fully assess this family. While there is no suggestion that this led directly to Dylan's death, we have nonetheless addressed the issues the coroner raised, ensuring that the best possible arrangements are followed to protect children from harm."

She added: "I am pleased the coroner has recognised that, along with other agencies, we have already taken a number of actions which address the weaknesses this case highlighted, including improving information sharing, the quality of assessments and record keeping.

"This involves ongoing training and improvements to ensure practitioners are up to date with the latest best practice to deal with a range of issues such as self harm and identifying risks to child safety.

"There are also a number of new developments including the multi-agency Domestic Abuse Referral Team, which provide a more comprehensive response to incidents of domestic violence."

Paul Burnett, chairman of the city's Safeguarding Children Board, said: "We extend our sincere sympathies to the family and friends of Dylan who sadly died at his home at a tragically young age. We have already identified the issues raised during the inquest and have worked with agencies to change procedures to ensure that practice improves."

22 comments

this is my old sw a long time ago he never cared about what was going on if we ever needed help he was NEVER there but the instant some one says " something wrong" when 99% of the time the person reporting was the person unsettling my babys hammering on the doors at all hours to wake them, he would be round like a shot " your children were crying all night " rohan griffiths is a self centred a-hole n i was so glad to stick my middle finger up at him when i got rid of him, this poor family deserved much better my heart goes out to them, unfortunatley we get some bum a-hole sw in our life n we have to suck it up til a better one arrives but for some families its just a lil too late

Oh bore off.
It addresses the fact that you're a presumptuous noddy who is factually incorrect a lot of the time whilst using their baseless aspersions to reinforce already weak points which are politically motivated.
Poor attempt Neo and you're starting to look a tad daft I'm afraid. Sorry - it's just true.

FAO sg and ted. you are both obviously in denial of sg's linking of overseas aid and this story in his earlier post. overseas aid IS a Ukipper hobby-horse, and like sg was unaware of this, and more to the point, that you were ted. the funny thing is this; for all of sg's posturing, does he really think that if the overseas aid budget were to be cancelled altogether, that the money would end up in the hands of public sector workers such as social workers? Not really likely is it, especially when the right like to bash such people anyway.

edmundirvine
I'm well paid for what I do. That's because I do not have to see horror every day or go to court and give evidence behind closed screens for fear of reprisal or have case loads so high that people blame me for the death of children. No offence but I don't think you really know what you're talking about.